Dissection-related tandem occlusion may be different from atherothrombotic tandem occlusion.

OBJECTIVES: The optimal endovascular treatment for tandem occlusion in anterior circulation ischaemic stroke remains unknown. The aim of this study was to examine how the aetiology of carotid pathology, dissection versus atherothrombosis, affects clinical outcomes. MATERIALS AND METHODS: Data was obtained from prospectively collected registries from two stroke centres between April 2016 and December 2020. Tandem cases with complete cervical internal carotid artery (ICA) occlusion or near-total occlusion (≥90% stenosis) were included. Patients were divided into two groups based on carotid pathology: dissection versus atherothrombosis. RESULTS: A total of 134 patients were included: 36 were dissection and 98 were atherothrombosis. The dissection group had better clinical outcomes compared to the atherothrombosis group, although after adjusting for age and stroke risk factors differences were non-significant. In the non-stented cohort, the dissection patients achieved a better outcome (modified Rankin scale 0-2) than atherothrombotic patients (57% vs. 34%, p=0.04) at 90-days. CONCLUSION: Dissection-related tandem occlusions appear to have different clinical features from atherothrombotic tandem occlusions which suggests different management strategies are needed.

Young Adults Rehabilitation Needs and Experiences following Stroke (YARNS): A review of digital accounts to inform the development of age-appropriate support and rehabilitation.

AIMS: To explore younger adults' experiences of stroke rehabilitation to inform practice, education and future health policy. DESIGN: Qualitative analysis of digital and other media sources on public platforms. METHODS: Between March and June 2020, the experiences of younger adult stroke survivors aged 18 to 45 at the time of the stroke were collected. Data were gathered from publicly available sources, including social media, and from English-speaking users. In total, 117 accounts from 103 participants were identified from films, autobiographical books, blogs, websites, videos, Twitter and Instagram. Data analysis followed narrative and multimodal analysis with a focus on rehabilitation needs. RESULTS: Younger adult stroke survivors make sense of their experience by reflecting on how stroke has impacted their lives. Accounts reflected an emotional journey between the past self, the present self and evolving self, as well as associated challenges such as the impact on relationships and careers. The majority of accounts presented transitions as problematic, including the receipt of the initial diagnosis, or sometimes misdiagnosis, to returning home and achieving long-term rehabilitation goals. Specialist stroke nurses were considered essential in the rehabilitation process. CONCLUSION: A complex process of recovery follows stroke for younger adult stroke populations. Challenges to the rehabilitation process need to be better understood and the role of nursing highlighted in future service provision. A series of age-related challenges were highlighted that require attention to improve the care and support offered. IMPACT: This article informs clinicians, educators, and policymakers of the age-related needs of young adult stroke survivors. Focusing on the individual and the development of age-appropriate person-centred stroke care is important. The study highlights the role of stroke nursing and challenges the current policy focus on older stroke populations as well as arguing for greater awareness of age-appropriate stroke rehabilitation in younger adults following stroke.

Hub-and-spoke model for thrombectomy service in UK NHS practice.

Mechanical thrombectomy is a highly effective but time dependent treatment for acute ischaemic stroke due to large vessel occlusion. In the UK, the national clinical guidelines for stroke and National Institute for Health and Care Excellence guidance endorses thrombectomy as an acute stroke treatment, and NHS England commissioned thrombectomy services. However, there are no UK 'real-world' data to verify the efficacy of the hub-and-spoke model in thrombectomy. There are currently 24 tertiary neuroscience centres in the UK that can provide thrombectomy treatment and many of these operate only within working hours. This study is the first to demonstrate that a hub-and-spoke thrombectomy service in routine UK 24/7 clinical practice is as effective and safe as in the setting of randomised controlled clinical trials. However, there are 9.3% of patients accepted for transfer to the thrombectomy centre who did not proceed to thrombectomy, mostly due to delays. Fifty-three per cent of thrombectomy cases were performed outside of standard working hours when transfer delays were increased. A 24/7 thrombectomy service is needed to maximise the benefit to all suitable patients. Measures, including improving workflow and optimising work forces, are needed to minimise the delays and continue to improve the service.

Shoulder pain after recent stroke (SPARS): hemiplegic shoulder pain incidence within 72hours post-stroke and 8-10 week follow-up (NCT 02574000).

OBJECTIVES: This study aimed to identify very early incidence of hemiplegic shoulder pain within 72hours (HSP), how clinical assessment was related to pain at 8-10 week follow-up and explore current standard therapy/management. DESIGN: Observational, prospective. SETTING: Teaching hospital hyper-acute and follow-up stroke services. PARTICIPANTS: 121 consecutive patients with confirmed cerebral infarct/haemorrhage recruited within 72hours of stroke onset. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Subjective report of pain severity and aggravating factors: using numerical rating scales and pain questionnaire (ShoulderQ), shoulder abductor and flexor muscle strength (Oxford MRC Scale), Neer's Test of sub-acromial pain, shoulder subluxation and soft tissue shoulder palpation. RESULTS: At initial assessment (<72hours), 35% (42/121) reported HSP. At follow-up (8-10 weeks), 44% (53/121) had pain: pain persisted in 32 of the original 42, resolved in 10 and had developed since initial assessment in 21. Pain at follow-up was associated with a statistically significant higher frequency of severe shoulder muscle weakness (MRC grade ≤2) and gleno-humeral subluxation at initial assessment. Soft tissue palpation and Neer's Test detected pain but did not predict development of HSP. 50/121 patients had 140 therapy interventions, particularly targeted to those with a higher HSP risk. CONCLUSION: This study reports HSP at an earlier time point after stroke than previous publications. Patients with severe arm weakness and/or shoulder subluxation within 72hours are at significantly higher risk of HSP at 8-10 weeks. These data highlight the high incidence of HSP, the non-standardized therapy approach, and can inform sample size calculations for future intervention studies. CLINICAL TRIAL REGISTRATION: NCT02574000 (clinicaltrials.gov).

Hyperacute neurology at a regional neurosciences centre: a 1-year experience of an innovative service model.

St George's Hospital hyperacute neurology service (HANS) is a comprehensive, consultant-delivered service set in a teaching hospital regional neuroscience centre. The service addresses deficiencies in acute neurological care previously highlighted by the Royal College of Physicians and the Association of British Neurologists. HANS adopts a disease-agnostic approach to acute neurology, prioritising the emergency department (ED) management of both stroke and stroke mimics alike alongside proactive daily support to the acute medical unit and acute medical take. Rapid access clinics provide a means to assess ambulatory patients, providing an outlet to reduce the burden of referral from primary care to acute medicine. This paper reports the results from the first year of the service. Admission was avoided in 25% of the cases reviewed in the ED. Compared to historic data, there was a significant improvement in the length of stay for non-stroke disorders while the occupancy of stroke beds by non-stroke cases reduced by 50%. The configuration of this service is replicable in other neuroscience centres and provides a framework to reduce the barriers facing patients who present with acute neurological symptoms.

How is stroke thrombolysis portrayed in UK national and London local newspapers? A review and critical discourse analysis.

BACKGROUND: thrombolysis for stroke has been licensed in the UK since 2007 and needs to be administered within 4.5 h. Given this time critical factor, the media may have an important role in public awareness. METHODS: this review aimed to find out how stroke thrombolysis was reported in UK national and London local newspapers and how treatment risks and benefits were communicated. Newspapers published between 1 January 2007 and 31 March 2010 were searched for articles on thrombolysis. Fifty-six articles were included and dispositive analysis, a qualitative analysis method, was used to identify themes. RESULTS: four main themes were identified: inaccurate description of thrombolysis, stroke clinicians' involvement, presentation of risks and benefits and patient stories. Inaccuracies included the presentation of thrombolysis as a treatment for transient ischaemic attack. Clinicians were quoted to suggest that thrombolysis produced complete recovery but were not reported to discuss risks or broader stroke management. The articles reported little or no risks of treatment. Patients' stories were used to reinforce that thrombolysis produces full recovery. CONCLUSIONS: this review found that newspaper media provides the public with inaccurate perspectives on thrombolysis. Clinicians may wish to check press articles prior to publishing and to consider the impact of reporting thrombolysis as a treatment which produces complete recovery.